Chapter 1

d. The superior mesenteric artery.

f f. The renal arteries.

g. The inferior mesenteric artery.

h. The vas deferens bending over the epigastric artery and the os pubis, after having passed through the internal abdominal ring.

[Footnote 2: The effusion of fluid into the pleural sac (from whatever cause it may arise) sometimes takes place to a very remarkable extent. I have had opportunities of examining patients, in whom the heart appeared to be completely dislocated, from the left to the right side, owing to the large collection of serous fluid in the left pleural sac. The heart's pulsations could be felt distinctly under the right nipple. Paracentesis thoracis was performed at the point indicated in PLATE 26. In these cases, and another observed at the Hotel Dieu, the heart and lung, in consequence of the extensive adhesions which they contracted in their abnormal position, did not immediately resume their proper situation when the fluid was withdrawn from the chest. Nor is it to be expected that they should ever return to their normal character and position, when the disease which caused their displacement has been of long standing.]

DESCRIPTION OF PLATE 26.

A. The systemic aorta. Owing to the body being inclined forwards, the root of the aorta appears to approach too near the lower boundary (N) of the thorax.

B. The left brachio-cephalic vein.

C. Left subclavian vein.

D. Right brachia-cephalic vein.

E. Left common carotid artery.

F. Brachio-cephalic artery.

G G*. The first pair of ribs.

H. Superior vena cava.

I. Left bronchus.

K K*. Fourth pair of ribs.

L. Descending thoracic aorta.

M. Oesophagus.

N. Epigastrium.

O. Left kidney.

P. Umbilicus.

Q. Abdominal aorta, at its bifurcation.

R R*. Right and left iliac fossae.

S. Left common iliac vein.

T. Inferior vena cava.

U. Psoas muscle, supporting the right spermatic vessels.

V. Left external iliac artery crossed by the left ureter.

W. Right external iliac artery crossed by the right ureter.

X. The rectum.

Y. The urinary bladder, which being fully distended, and viewed from above, gives it the appearance of being higher than usual above the pubic symphysis.

Z. Pubic symphysis.

2. The left internal abdominal ring complicated with the epigastric vessels, the vas deferens, and the spermatic vessels.

3. The right internal abdominal ring in connection with the like vessels and duct as that of left side.

4. Superior mesenteric artery.

5, 6. Right and left external iliac veins.

7, 8. Situations of the anterior superior iliac spinous processes.

9, 10. Situations of the coracoid processes.

11, 12. Right and left hypochondriac regions.

The close relations which the cord, D F, bears to the saphenous opening, E, of the fascia lata, should be closely considered, forasmuch as when an oblique inguinal hernia descends from D to F, it approaches the situation of the saphenous opening, E, which is the seat of the femoral or crural hernia, and both varieties of hernia may hence be confounded. But with a moderate degree of judgment, based upon the habit of referring the anatomy to the surface, such error may always be avoided. This important subject shall be more fully treated of further on.

The superficial bloodvessels of the inguino-femoral region are, e e, the saphenous vein, which, ascending from the inner side of the leg and thigh, pierces the saphenous opening, E, to unite with the femoral vein. The saphenous vein, previously to entering the saphenous opening, receives the epigastric vein, i, the external circumflex ilii vein, h, and another venous branch, d, coming from the fore part of the thigh. In the living body the course of the distended saphenous vein may be traced beneath the skin, and easily avoided in surgical operations upon the parts contained in this region. Small branches of the femoral artery pierce the fascia lata, and accompany these superficial veins. Both these orders of vessels are generally divided in the operation required for the reduction of either the inguinal or the femoral strangulated hernia; but they are, for the most part, unimportant in size. Some branches of nerves, such as, k, the external cutaneous, which is given off from the lumbar nerves, and, f, the middle cutaneous, which is derived from the crural nerve, pierce the fascia lata, and appear upon the external side and middle of the thigh.

Numerous lymphatic glands occupy the inguino-femoral region; these can be felt, lying subcutaneous, even in the undissected state of the parts. These glands form two principal groups, one of which, c, lies along the middle of the inguinal fold, C B; the other, G g, lies scattered in the neighbourhood of the saphenous opening. The former group receive the lymphatic vessels of the generative organs; and the glands of which it is composed are those which suppurate in, syphilitic or other affections of these parts.

The general relations which the larger vessels of the inguino-femoral region bear to each other and to the superficies, may be referred to in PLATE 27, with practical advantage. The umbilicus, A, indicates pretty generally the level at which the aorta bifurcates on the forepart of the lumbar vertebrae. In the erect, and even in the recumbent posture, the aorta may (especially in emaciated subjects) be felt pulsating under the pressure of the hand; for the vertebrae bear forward the vessel to a level nearly equal with, C C, the anterior superior spinous processes of the iliac bones. If a gunshot were to pass through the abdomen, transversely, from these points, and through B, it would penetrate the aorta at its bifurcation. The line A B coincides with the linea alba. The oblique lines, A D, A D,* indicate the course of the iliac vessels. The point D marks the situation where the spermatic vessels enter the abdomen; and also where the epigastric artery is given off from the external iliac. The most convenient line of incision that can be made for reaching the situation of either of the iliac arteries, is that which ranges from C, the iliac spine, to D, the point where the spermatic cord enters the abdomen. The direct line drawn between D and G marks the course of the femoral artery, and this ranges along the outer border, E, of the saphenous opening.

DESCRIPTION OF PLATE 27.

A. The umbilicus.

B. The upper margin of the pubic symphysis.

C. The anterior superior spine of the left iliac bone. C*, the situation of the corresponding part on the right side.

D. The point where, in this subject, the cord manifested itself beneath the fibres of the external oblique muscle. D*, a corresponding part on the opposite side.

E. The saphenous opening in the fascia lata, receiving e, the saphenous vein.

F. The lax and pendulous cord, which in this case, overlies the upper part of the saphenous opening.

G. Lymphatic glands lying on the fascia lata in the neighbourhood of the saphenous opening.

H. The fleshy part of the external oblique muscle.

a a a. The superficial fascia of the abdomen.

b. The same fascia forming an envelope for the spermatic cord and scrotum.

c. Inguinal glands lying near Poupart's ligament.